Skilled Charting

by Julianne Haydel on March 26, 2012

Our small little company probably sees more denials than anyone else other than say Palmetto or one of the Zone contractors. So we make a lot of fuss about documentation and getting paid but while we are very good about finding errors, we don’t offer as much as we should in teaching documentation with payment in mind. I’m not going to bother with that now as I have a lot to do so let me just show some examples of bad, better and really good documentation.

Skilled Teaching – Diet

Best: Taught American Heart guidelines for low sodium diet according to handout pages 1 and 2. Copy attached and left in home folder.

Homebound Status

Bad: SOB on exertion (everyone gets short winded if they exert themselves enough)

Better: Patient is short of breath when walking 20 feet.

Best: Patient is unable to leave the home due to SOB r/t CHF, arthritic pain and impaired judgment due to narcotic medications. Requires cumbersome assist devices and at least one person to help leave the home.

Diabetes Foot Check

Bad: Taught patient to perform foot care.

Better: Inspected all surfaces of feet. No problems noted. Patient was able to demonstrate foot care with a mirror.

Best: Inspected all surfaces of feet while simultaneously instructing patient on foot care and (proper footwear), (risks of decreased sensitivity), (risks of going without shoes), (when to see podiatrist), (importance of annual eye exam). Take your pick and rotate through the list.

PT/INR

Bad: PT/INR drawn per orders and brought to lab.

Better: PT/INR drawn per orders. Called team leader to watch for results.

Any0ne else care to add to the list? Yes, you’ll chart a little more but if you blow off the recap of what is on the flow sheet – assessed all body systems, patient awake alert and oriented times 3, denies pain, etc., etc., you may find that you write less and say more. Better yet, you will get paid for your hard work and your outcomes will improve as well.

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We had a survey recently and one of our nurses documented that she taught a low sodium diet to the patient (CHF) using the American Heart guidelines but since the 485 said regular diet, we were “dinged” for teaching that without an MD order. What do you think about that?

I think the surveyor probably dinged you under ‘nursing services’ and hopefully she was kind enough to make it a standard deficiency instead of a conditional one. You know it’s conditional if they promise to come back before the 45th day. The problem isn’t with the nurse charting in the field. The problem was with the care plan. It is self evident to everyone but surveyors that CHF patients need to be on a restricted sodium diet. However, once the MD signs a plan of care, everything on the POC becomes an order. So, the MD ordered a ‘regular’ diet which is interpreted as a having no restrictions and your nurse taught a therapeutic diet. In the worst possible light, your nurse did not follow MD orders. Imagine if that was the only thing you knew about the nurse – she doesn’t follow MD orders.

There is a great teaching tool for healthy eating in the elderly. I am going to try to upload and post a link on the sidebar for it. It is an episode worth of teaching (along side other skills) and it emphasizes sane amounts of sodium, low fat, lots of veggies, talks about buying food with limited funds, cooking methods, etc. Nobody could fault you for teaching on that as a general rule. If the order had read low sodium, it would fit the guidelines and if the order read regular, the lowered sodium content would have suited a CHF patient.

Sorry this happened to you. It was more about the care plan. Trust me.

You are so right! The one I like best is: taught hypertension can cause stroke, heart attack or death followed by……..nothing. I bet those patients are grateful to have a nurse come by an cheer them up. You may want to add ‘or when to call nurse’ depending on where the patient lives. If someone can get there within a short amount of time, it may save the patient a trip to the ER or MD office. Sometimes a headache is just a headache and with summer coming, there will be a lot of dehydrated patients down here feeling ‘dizzy’.

Good:Instructed in HEP for strengthening of LE with copy given to patient and attached to chart. Pt verbal understanding with written cues.

Best:Patient instructed in HEP to focus on stabilization of left hip via closed chain exercises. Written copy given to patient and attached to chart. Instructed patient in signs and symptoms that warrant a reduction in exercise and or when to stop and call the PT, the physician, or 911. Instructed on how to progress program properly. Patient and spouse verbal understanding and were able to demonstrate with good mechanics.

Ben, this is good, I think. I do not know what closed chain means in this context. I do know what 10 reps of leg extensions are and often wonder the skills of a therapist are required for that. So, if this is a skill that is special to physical therapists, it is excellent. Took a little longer than the bad choice. But in front of an administrative law judge, you would prevail. The judge could easily ask why the patient couldn’t watch the fitness channel if all he needed was a home exercise program. But to the best of my knowledge there are no 30 minute work out shows that address stabilization of a left (or right) hip. Great example.